Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study.

BACKGROUND: The authors tested the hypotheses that, compared with an overnight continuous femoral nerve block (cFNB), a 4-day ambulatory cFNB increases ambulation distance and decreases the time until three specific readiness-for-discharge criteria are met after tricompartment total knee arthroplasty. METHODS: Preoperatively, all patients received a cFNB (n = 50) and perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomly assigned to either continue perineural ropivacaine or switch to perineural normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4. RESULTS: Patients given 4 days of perineural ropivacaine attained all three discharge criteria in a median (25th-75th percentiles) of 25 (21-47) h, compared with 71 (46-89) h for those of the control group (estimated ratio, 0.47; 95% confidence interval, 0.32-0.67; P <0.001). Patients assigned to receive ropivacaine ambulated a median of 32 (17-47) m the afternoon after surgery, compared with 26 (13-35) m for those receiving normal saline (estimated ratio, 1.21; 95% confidence interval, 0.71-1.85; P = 0.42). CONCLUSIONS: Compared with an overnight cFNB, a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 53% after tricompartment total knee arthroplasty. However, the extended infusion did not increase ambulation distance the afternoon after surgery. (ClinicalTrials.gov No. NCT00135889.).

Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study.

BACKGROUND: A continuous interscalene nerve block (CISB) may be used to provide analgesia after shoulder arthroplasty. Therefore, inpatient stays may be shortened if CISB (1) provides adequate analgesia without intravenous opioids and (2) improves shoulder mobilization. This study investigated the relationship between ambulatory CISB and the time to reach three discharge criteria after shoulder arthroplasty. METHODS: Preoperatively, patients received a CISB. All patients received a perineural 0.2% ropivacaine infusion from surgery until 06:00 the following morning, at which time they were randomly assigned either to continue perineural ropivacaine or to switch to normal saline. The primary endpoint was the time from the end of surgery until three discharge criteria were attained (adequate analgesia, independence from intravenous analgesics, and tolerance to 50% of shoulder motion targets). Patients were discharged home as early as the afternoon after surgery with their CISB using a portable infusion pump. RESULTS: Patients receiving perineural ropivacaine (n = 16) attained all three discharge criteria in a median (10th-90th percentiles) of 21 (16-41) h, compared with 51 (37-90) h for those receiving perineural normal saline (n = 13, P < 0.001). Unlike patients receiving perineural ropivacaine, patients receiving perineural normal saline often required intravenous morphine, but still experienced a higher degree of pain and tolerated less external rotation. CONCLUSIONS: An ambulatory CISB considerably decreases the time until readiness for discharge after shoulder arthroplasty, primarily by providing potent analgesia that permits greater passive shoulder movement and the avoidance of intravenous opioids. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with earlier discharge.

Total hip arthroplasty as an overnight-stay procedure using an ambulatory continuous psoas compartment nerve block: a prospective feasibility study.

OBJECTIVE: Total hip arthroplasty (THA) results in severe postoperative pain requiring hospitalization to provide potent analgesia. Consequently, the average duration of hospitalization after THA in the United States is 4 to 5 days. This prospective study investigated the feasibility of converting THA into an overnight-stay procedure using a continuous psoas compartment nerve block provided at home with a portable infusion pump. CASE REPORT: Preoperatively, patients undergoing THA had a psoas compartment perineural catheter placed. Postoperatively, perineural ropivacaine 0.2% was delivered through postoperative day (POD) 4. Patients were discharged home when they met specific, prospectively defined criteria, as early as POD 3 for the first phase and POD 1 for the second phase. Of the patients in the first phase (n = 7) who remained hospitalized for at least 3 postoperative nights, 5 met discharge criteria on POD 1 and the remainder on POD 2. Of the patients in phase 2 (n = 5), all but 1 met discharge criteria on POD 1 and 3 were discharged directly home on POD 1. Postoperative pain was well controlled, opioid requirements and sleep disturbances were minimal, and patient satisfaction high. CONCLUSIONS: These results suggest that for a subset of patients without major comorbidities, it is feasible to convert THA into an overnight-stay procedure using an ambulatory continuous psoas compartment nerve block as part of a multimodal analgesic regimen provided at home. Additional research is required to replicate these results in a controlled trial, define the appropriate subset of patients, and assess the incidence of complications associated with this practice before its mainstream use.

Total knee arthroplasty as an overnight-stay procedure using continuous femoral nerve blocks at home: a prospective feasibility study.

The average duration of hospitalization after total knee arthroplasty (TKA) in the United States is 4-5 days. In this two-phase study we investigated the feasibility of converting TKA into an overnight-stay procedure using a continuous femoral nerve block provided at home through postoperative day 4. Nine of 10 patients met discharge criteria and were discharged home the day after surgery. Pain was well controlled, opioid requirements and sleep disturbances were minimal, and patient satisfaction was high. Additional research is required to replicate these results in a controlled trial, define the appropriate subset of patients, and assess the incidence of complications associated with this practice before its mainstream use.

Total shoulder arthroplasty as an outpatient procedure using ambulatory perineural local anesthetic infusion: a pilot feasibility study.

We investigated the feasibility of converting total shoulder arthroplasty (TSA) into an outpatient procedure using ambulatory interscalene perineural ropivacaine infusion. Of the patients of the first phase (n = 8) who were required to remain hospitalized for at least 1 postoperative night, 5 met discharge criteria in the recovery room. Of the subsequent patients of the second phase (n = 6), all met discharge criteria in the recovery room after surgery, and 5 were discharged directly home. For all patients, postoperative pain was well controlled, oral opioid requirements and sleep disturbances were minimal, range-of-motion consistently reached or exceeded the surgeon's expectations, and patient satisfaction was high. These results suggest that TSA may be performed on an outpatient basis using perineural local anesthetic infusion. Additional research is required to define the appropriate subset of patients and assess the incidence of complications associated with this practice before its mainstream use.